URAC Consulting

Of all the new standards proposed for the revised Health Plan/Health Network v. 5.1 standards, this is the most significant, if only for its length and therefore for the relative weight in the new scoring system.  It reads:

If the organization creates programs for physician or other provider performance measurement, reporting and tiering (including rating, ranking or measurement designations): [--]
(a) Accurate, reliable, and valid measures must be used, and [--]
(i) Endorsed by the National Quality Forum where available; and [3]
(ii) If not available, then the Ambulatory Quality Alliance, the AMA-convened PCPI, or national accreditor-endorsed measures are used; and [3]
(iii) If none of the above are available, then measures based upon nationally recognized practice guidelines are used. [3]
(b) Measures used must be: [--]
(i) Clearly delineated; and [3]
(ii) Appropriately risk adjusted to account for characteristics of the physician’s or other provider’s patient population such as case mix, severity of patient’s condition, comorbidities, and outlier populations. [4]
(c) Categories of measurement cannot exclusively include cost efficiency, but must also include quality of performance. [M]
(i) Both types of measures are calculated and reported separately; and [M]
(ii) If combined, the individual component scores and their proportion of the combined score must be disclosed separately. [M]
(d) When comparing or ranking physicians and other providers: [--]
(i) The relative weight of each measure and each type of measure must be publicly available; [4]
(ii) Cost efficiency measures must compare physicians and other providers by specialty area or peer group and geography. [4]
(e) Data: [--]
(i) Must describe statistical basis for number of patients (data) used; and [3]
(ii) Must use current data consistent with the proper timeframe to attain adequate sample sizes. [3]

As you can see, it has 3 mandatory subsections and 30 other "scoring points", making this about as consequential a standard as you'll find anywhere in the revised standards.  

This standard does five basic things:

1. Establishes a minimum threshold for the source of the measures to be used the performance measurement system;
2. Requires risk adjustment;
3. Insists on the inclusion of quality measures and thereby prohibits cost-efficiency-only performance measurement;
4. Creates standards of fairness in the use of performance measures to compare providers; and
5. Establishes minimum requirements -- albeit vague ones -- for the statistical validity of the measures being used, with particular attention on sampling methodology.

One can assume that the documentation for this standard will need to be extensive.  Most of it, I'm imagining, will be submitted during the AccreditNet phase of the application process -- extensive P&Ps, program descriptions, and documentation supporting the choices made about measurement selection and sampling methodology.  The onsite review, I'm guessing, will hold few surprises, assuming the initial documentation submission is sufficient to get past the desktop review.